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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000250
Report Date: 12/20/2023
Date Signed: 12/20/2023 01:28:21 PM

Document Has Been Signed on 12/20/2023 01:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MELMAR'S GUEST HOME #2FACILITY NUMBER:
397000250
ADMINISTRATOR:CAMERO, MARICORFACILITY TYPE:
735
ADDRESS:6801 MONTAUBAN AVENUETELEPHONE:
(209) 683-6876
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 4DATE:
12/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Maricor JunsonTIME COMPLETED:
01:45 PM
NARRATIVE
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On 12-20-23 at 10:45am Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding facility’s plan of operation and care and supervision. LPA met with Administrator Maricor Junson and explained the purpose of the visit. LPA conducted interview with Administrator and conducted a facility observation. Regional center representative was also present during this case management. Additionally, LPA reviewed facility sketch, and a previous regional center report dated 10-6-23.

During facility tour, LPA observed a room currently occupied by staff for living quarters. Based on facility sketch and regional center report, this area is designated as an “indoor recreation room” as reflected in the facility’s program design. Based on interview, it was determined that garage was converted for this purpose. It was further determined through record review and interviews that an updated program design/plan of operation reflecting the above change was not submitted to licensing department for review. Additionally, facility did not update facility sketch and initiate an updated fire clearance noting this converted area is now for staff use. Currently, based on observation and interview, this area is now locked and inaccessible to clients in care, which modifies the fire clearance.

{Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MELMAR'S GUEST HOME #2
FACILITY NUMBER: 397000250
VISIT DATE: 12/20/2023
NARRATIVE
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Additionally, during today’s case management, LPA reviewed regional center report and interviewed administrator. Based on records reviewed and interview, it was determined that on 9-18-23, a regional center case worker arrived and noted a staff member arriving at the same time. It was revealed at that time that staff did not have a key to enter the facility. Once case worker and staff entered the facility, client1 (C1) was witnessed to be in the backyard alone smoking resulting in an absence of supervision. Administrator arrived approximately 20 minutes later with the other clients. Upon further review by LPA, it was determined that C1 does not have the authorization to be in the home unsupervised based on current program design and C1’s IPP.

As a result of today’s case management, citations are issued under Title 22 Division 6 and noted on LIC 809D. Civil penalties in the amount of $500 each are issued today in addition to citations due to Fire Clearance and Care and Supervision violations. An exit interview was conducted with Maricor Junson and a copy of this report was provided to Maricor. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/20/2023 01:28 PM - It Cannot Be Edited


Created By: Michael Bilger On 12/20/2023 at 11:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MELMAR'S GUEST HOME #2
FACILITY NUMBER: 397000250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2023
Section Cited
CCR
80020(a)

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Fire Clearance. (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshall. This requirement was not met as evidenced by:
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Licensee to submit an updated LIC 200 and proposed facility sketch to LPA by POC due date for processing of updated fire clearance.

Licensee will read regulation 80020 and submit a signed declaration of understanding to LPA by POC due date.
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Based on record review, observation, and interview, licensee did not secure and maintain an updated fire clearance upon a converion of garage and a facility sketch change designating a previous recreation room as a staff member’s lodging. This posed an immediate health and safety risk to residents in care.
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Type A
12/21/2023
Section Cited
CCR80078(a)

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80078(a) Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee and staff will complete training on proper care and supervision. Training date to be sent to LPA by POC due date. Proof of completed training to be sent to LPA no later than 2 weeks from date of citation issuance.
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Based on record review and interview, Licensee did not ensure proper care and supervision for C1 in that C1 was left alone at facility without staff supervision. This posed an immediate health and safety risk to clients in care.
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Licensee will submit staffing schedule to LPA for the following 6 weeks to indicate assurance of staff coverage for clients in care. Schedule to be submitted to LPA by POC due date.

Licensee to read regulation 80078(a) and submit a signed declaration of understanding to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/20/2023 01:28 PM - It Cannot Be Edited


Created By: Michael Bilger On 12/20/2023 at 12:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MELMAR'S GUEST HOME #2
FACILITY NUMBER: 397000250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
80022(j)

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Plan of Operation. (j) Any changes in the plan of operation which affect the services to clients shall be subject to licensing agency approval and shall be reported as specified in Section 80061.This requirement was not met as evidenced by:
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Licensee will read regulation 80022(j) and provide a signed declaration of understanding to LPA by POC due date.
Licensee will provide an updated plan of operation to reflect above changes. Update to be send to LPA by POC due date.

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Based on record review and interview, facility did not submit a change in plan of operation to licensing department which affected services to clients. A previously designated recreation room is no longer available to clients in care. This posed a potential health and safety risk to clients in care.
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Type B
12/29/2023
Section Cited
CCR80064(a)(3)

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Administrator – Qualifications and Duties. (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by:
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Licensee will read regulation 80064(a)(3) and submit a signed declaration of understanding to LPA by POC due date.
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Based on record review and interview, Administrator did not exercise knowledge of applicable laws and regulations in that a change in plan of operation and fire clearance were not initiated, and a client was left unsupervised without Administrator ensuring approval. This posed a potential health and safety risk to clients in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


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